Report on Medicare Compliance

  1. OIG Is Developing 'Guardrails' for Telehealth Services; Prepare for 'Cleanup on Back End'

    Report on Medicare Compliance Volume 29, Number 39. November 02, 2020  | Author: Nina Youngstrom  | November 02, 2020 

    Troubled by some of the telehealth practices it’s seeing, the HHS Office of Inspector General (OIG) is developing “guardrails” and standards to help protect Medicare from fraud and abuse now that its doors are wide open to telehealth during the COVID-19 public health emergency (PHE) and possibly beyond...

  2. CMS Hikes Payment for COVID-19 Inpatients Treated With New Drugs, Links it to 20% Bonus

    Report on Medicare Compliance Volume 29, Number 39. November 02, 2020  | Author: Nina Youngstrom  | November 02, 2020 

    CMS said Oct. 28 that Medicare will pay hospitals extra when they treat inpatients with drugs or biologicals approved by the Food and Drug Administration (FDA) for COVID-19. The additional payments are linked to the 20% bonus hospitals already receive for COVID-19 MS-DRGs, and both require proof of a positive COVID-19 test, according to the fourth interim final rule with comment period (IFC).[1] CMS also raised the specter of post-payment reviews...

  3. Information-Blocking Rule Is Delayed Until April; It's a 'Pretty Huge Cultural Change'

    Report on Medicare Compliance Volume 29, Number 39. November 02, 2020  | Author: Nina Youngstrom  | November 02, 2020 

    A hospital employee laughs at an email from a competitor asking for patient information for a quality assessment study. The email has a list of admissions, including patient names, dates of birth and discharge dates, and the employee is asked to match them to the hospital’s patient list and the patients of unaffiliated community providers that share the hospital’s electronic health records (EHRs), and then send over discharge summary notes and consultation notes for every encounter within 90 days of discharge. “There’s no way I’m going to hand over so much sensitive patient information to a competitor,” the employee thinks...

  4. Checklist for Compliance With Information-Blocking Rule

    Report on Medicare Compliance Volume 29, Number 39. November 02, 2020  | Author: Nina Youngstrom  | November 02, 2020 

    Here’s a checklist to help hospitals, physicians and other “actors” take steps to comply with the information-blocking regulation from HHS’s Office of the National Coordinator for Health Information Technology. The checklist is part of the information-blocking tool kit developed by the law firm Davis Wright Tremaine. The compliance date of the regulation was Nov. 2, but on Oct. 29, HHS delayed it until April 5 because of the COVID-19 public health emergency. [1] Contact attorney Adam Greene at adamgreene@dwt.com...

  5. CMS Transmittals and Federal Register Regulations, Oct. 23-29

    Report on Medicare Compliance Volume 29, Number 39. November 02, 2020  | November 02, 2020 

  6. News Briefs: November 2, 2020

    Report on Medicare Compliance Volume 29, Number 39. November 02, 2020  | Author: Nina Youngstrom  | November 02, 2020 

    ◆ Medtronic USA Inc., a medical device maker, has agreed to pay $8.1 million to settle allegations it violated the False Claims Act by paying kickbacks to induce South Dakota neurosurgeon Wilson Asfora, M.D., to use its SynchroMed II intrathecal infusion pumps, the Department of Justice said Oct. 29.[1] According to the settlement,[2] Medtronic knew that Asfora and his wife owned a restaurant in Sioux Falls called Carnaval Brazilian Grill. Asfora allegedly told Medtronic that business was slow and asked the device maker to pay for events there. “Contrary to Medtronic’s established written compliance policies, Medtronic agreed to Asfora’s request,”...

  7. CMS Limits ADRs During COVID-19 as Audits Pick Up; Reviewers Will Grant Extensions

    Report on Medicare Compliance Volume 29, Number 38. October 26, 2020  | Author: Nina Youngstrom  | October 26, 2020 

    If the COVID-19 pandemic is interfering with their ability to fulfill audit demands, hospitals and other providers should ask for leniency from Medicare auditors, top CMS program integrity officials say. Auditors are expected to push back deadlines if necessary, and they must reduce the number of additional documentation requests (ADRs) temporarily. Meanwhile, Targeted Probe and Educate (TPE), the prepayment reviews by Medicare administrative contractors (MACs), is still on ice, except in connection with potential fraud referrals. But TPE will definitely return...

  8. Payers Push Back on Respiratory and Other Principal Diagnoses; 'It's Insane This Is a Thing'

    Report on Medicare Compliance Volume 29, Number 38. October 26, 2020  | Author: Nina Youngstrom  | October 26, 2020 

    When a Missouri hospital submitted a claim with a principal diagnosis of pneumonia, the commercial payer swapped it out for respiratory failure, which changed the MS-DRG, something that’s repeated in some form or another by many payers, probably at most hospitals, with respiratory diagnoses a popular target. The hospital appealed because the admission order included both conditions, and coding guidelines allow hospitals to sequence the principal diagnosis of their choice if either occasioned the admission, coders and lawyers say...

  9. First CMS Audit of 20% Bonus for COVID-19 Inpatients Gets Underway

    Report on Medicare Compliance Volume 29, Number 38. October 26, 2020  | Author: Nina Youngstrom  | October 26, 2020 

    CMS’s first medical review of the 20% add-on payment for treating COVID-19 inpatients is underway, and hospitals should keep their eyes peeled for documentation requests. The audit is not touching on the Sept. 1 requirement for proof of a positive lab test to qualify for the 20% Medicare bonus, but probably will sooner rather than later. There’s a twist, as coders and clinical documentation improvement (CDI) specialists increasingly find documentation of positive coronavirus tests in the medical records without a corresponding diagnosis because patients have recovered and their physicians don’t believe they’re contagious, experts say...

  10. A Brief Primer on Compliant Billing for Inpatients With COVID-19

    Report on Medicare Compliance Volume 29, Number 38. October 26, 2020  | Author: Nina Youngstrom  | October 26, 2020 

    Here are some important storylines for hospitals to follow to ensure compliance with Medicare rules on billing for inpatients diagnosed with COVID-19, according to Deloitte.[1] There’s a 20% add-on payment during the public health emergency if hospitals have documentation of a positive coronavirus test in the patient’s medical record. Contact Kelly Sauders, a partner in Deloitte, at ksauders@deloitte.com...

  11. CMS: M.D.s Requesting Prior Auth for Hospitals Could 'Bridge Gap'

    Report on Medicare Compliance Volume 29, Number 38. October 26, 2020  | Author: Nina Youngstrom  | October 26, 2020 

    As it carries out the new prior authorization process[1] for five hospital outpatient procedures, with two more in the wings and presumably more to come, CMS has opened its eyes to the challenges for hospitals, a program integrity official said Oct. 19 at CMS’s virtual Provider Compliance Focus Group...

  12. CMS Transmittals and Federal Register Regulations, Oct. 16-22

    Report on Medicare Compliance Volume 29, Number 38. October 26, 2020  | October 26, 2020 

  13. News Briefs: October 26, 2020

    Report on Medicare Compliance Volume 29, Number 38. October 26, 2020  | Author: Nina Youngstrom  | October 26, 2020 

    ◆ In a new provider compliance audit,[1] the HHS Office of Inspector General (OIG) said Gem City Home Care in Dayton, Ohio, was overpaid $40,621, which was extrapolated to $2.67 million. OIG audited 100 claims submitted in 2016 and 2017 and found errors on 25. The errors were attributed to claims for Medicare beneficiaries who weren’t homebound or didn’t need skilled services. OIG recommended Gem City refund the portion of the $2.67 million within the four-year reopening period and “exercise reasonable diligence to identify and return overpayments in accordance with the 60-day rule” outside the audit period. Gem City refuted...

  14. Hospitals Modify Some Arrangements Without Stark Waiver; Exceptions Are 'Preferable'

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | Author: Nina Youngstrom  | October 19, 2020 

    Some hospitals are giving free or discounted telehealth equipment to physician practices to promote telehealth visits with patients, protected by the blanket waivers of the Stark Law during the COVID-19 public health emergency.[1] While telehealth equipment is a good candidate for the waivers, hospitals might want to anticipate the aftermath, when the public health emergency ends and the waivers expire, because they probably won’t be able to provide the equipment at no charge, an attorney said...

  15. Stark Waivers Related to Fair Market Value and Valuation

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | Author: Nina Youngstrom  | October 19, 2020 

    The blanket waivers to the Stark Law, which HHS announced March 30, will continue until the end of the COVID-19 public health emergency. Some of them apply to fair market value and valuation in financial relationships (e.g., between hospitals and physicians). “The only waiver that protects above fair market value compensation relates to personally performed services,” said attorney Victoria Sheridan, with Epstein Becker & Green in Newark, New Jersey, who pulled together this list from the waivers (see story, p. 1).[1] “The waivers that apply to leases of office space and equipment only apply when remuneration is below fair market...

  16. Medicare Adds Telehealth Services Using New Process; Overlapping Policies Pose Risks

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | Author: Nina Youngstrom  | October 19, 2020 

    Medicare will now pay for 11 more services delivered by telehealth until the end of the COVID-19 public health emergency (PHE), CMS said Oct. 14.[1] Various CPT codes for cardiac rehabilitation, pulmonary rehabilitation with exercise, interrogation of ventricular assist device and implanted neurostimulator pulse generators have been added to the list of services that providers can bill for anywhere in the country. These are services provided by physicians and other practitioners...

  17. Numerous Agencies Oversee Telehealth Providers

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | Author: Nina Youngstrom  | October 19, 2020 

    Here are the agencies and entities that oversee telehealth providers, said attorney Jacob Harper, with Morgan Lewis in Washington, D.C.[1] “Compliance officers should make sure they understand the requirements of these entities,” Harper said. Contact him at jacob.harper@morganlewis.com...

  18. OIG: Hospital Was Overpaid $16M, Mostly for IRF; PPS Eases Burden

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | Author: Nina Youngstrom  | October 19, 2020 

    Although inpatient rehabilitation facilities (IRFs) got some administrative relief in the 2021 prospective payment system regulation,[1] it may not take the sting out of audits, because Medicare has a long list of precise coverage requirements for inpatient rehab and overarching expectations of medical necessity. The hit that hospitals may take is on display in a new HHS Office of Inspector General (OIG) provider compliance audit of Alta Bates Summit Medical Center in Oakland, California.[2] OIG contends the hospital was overpaid $1,571,741, which was extrapolated to $16.3 million, mostly because of IRF noncompliance. Alta Bates disagreed with most of OIG’s findings...

  19. Do Employees Know the CCO? Culture Surveys Reveal That and More

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | Author: Nina Youngstrom  | October 19, 2020 

    On a recent culture survey at TAMKO Building Products in Joplin, Missouri, employees were asked if they know who the compliance officer is...

  20. CMS Transmittals and Federal Register Regulations, Oct. 9-15

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | October 19, 2020 

  21. News Briefs: October 19, 2020

    Report on Medicare Compliance Volume 29, Number 37. October 19, 2020  | October 19, 2020 

    By Nina Youngstrom...

  22. HRSA Plans Several Audits of Provider Relief Fund; Reporting Requirements Raise Alarm

    Report on Medicare Compliance Volume 29, Number 36. October 12, 2020  | Author: Nina Youngstrom  | October 12, 2020 

    Providers should brace themselves for several different types of audits by the HHS Health Resources and Services Administration (HRSA), which administers the COVID-19 Provider Relief Fund. It has a “strong and robust program integrity component,” according to Joe Roach, the leader of the Program Integrity Team in the Office of Provider Relief at HRSA...

  23. HRSA's Oversight Strategy for Provider Relief Fund Money

    Report on Medicare Compliance Volume 29, Number 36. October 12, 2020  | October 12, 2020 

    Joe Roach, the lead of the Program Integrity Team in the Office of Provider Relief at the HHS Health Resources and Services Administration (HRSA), explained its oversight strategy for the Provider Relief Fund Oct. 1 at the Fraud and Compliance Forum sponsored by the American Health Law Association (see story, p. 1).[1]...

  24. Compliance Audit Manual Helps Keep Auditors on Same Page; Pre-Audit Surveys Are Useful

    Report on Medicare Compliance Volume 29, Number 36. October 12, 2020  | Author: Nina Youngstrom  | October 12, 2020 

    To give compliance auditors tools to go about their business uniformly, WellSpan Health in York, Pennsylvania, developed a comprehensive manual of its audit process, which was converted to an electronic version when employees headed home to work because of COVID-19. The audit manual doesn’t leave a lot to chance, with step-by-step guidance on researching risk areas, determining sample size, surveying departments before and after audits and presenting results to executives, among other things...

  25. Corporate Compliance Audit Process Checklist

    Report on Medicare Compliance Volume 29, Number 36. October 12, 2020  | Author: Nina Youngstrom  | October 12, 2020 

    To ensure consistency and efficiency in the audits at WellSpan Health in York, Pennsylvania, Compliance Audit Coordinator Frank Mesaros documented its audit process in a manual and then put it in an electronic form when everyone scattered because of COVID-19 (see story, p. 1).[1] Here’s one of the documents from the audit manual. Contact Mesaros at fmesaros@wellspan.org...